Bedside-focused transthoracic echocardiography in acute atraumatic thoracic aortic syndrome: a systematic review and meta-analysis of diagnostic accuracy.

The objective of this review is to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to the emergency care setting with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and Medical Subject Heading searches on databases and grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis (n = 4569 patients). The prevalence of Type A thoracic aortic dissection was 11% (range 1.4-45.7%) and Type B dissection was 7% (range 1.8-30.55%). Type A dissection through direct visualisation of an intimal flap on TTE (i.e. direct sign) pooled sensitivity and specificity were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%) respectively. For Type B dissection, the pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). TTE indirect signs for dissection showed a pooled sensitivity of 64% (95% CI, 5.2-98.2%) and specificity of 94% (95% CI, 92-96.1%) for aortic valve regurgitation, a pooled sensitivity of 92% (95% CI 54-99.2%) and specificity of 87% (95% CI, 62-97%) for thoracic aortic aneurysm and a pooled sensitivity of 39% (95% CI 33.8-45%) and a specificity of 94% (95% CI, 92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has a good specificity for Type A and B dissection, but poor sensitivity for Type B, and unclear for intramural haematoma and penetrating aortic ulcer.

Implementing a quality framework for storing emergency department point-of-care ultrasound examinations on a picture archiving and communication system.

INTRODUCTION: There is a lack of a quality framework in most emergency departments despite the set national standards for storing point-of-care ultrasound (PoCUS) examinations. To explore and address this problem, a quality improvement project was undertaken in an emergency department.Methods and interventions: A consecutive sample of the most recent PoCUS examinations in a district general hospital emergency department in the United Kingdom was audited. None was handled and stored on the picture archiving and communication system (PACS). Quality improvement project tools, such as plan, do, study, act (PDSA) cycles, were utilised to analyse and improve practice. The PoCUS machine was connected to the local area network to allow transfer of images to PACS. For requesting and booking the examinations, specific requests on the integrated clinical environment were created akin to the computerised radiology information system codes. Other interventions were introduced such as a reporting proforma. The success of the quality improvement project depended partly on key stakeholders such as emergency department consultants, radiology staff and PACS teams. The number of stored examinations on PACS was the main process measure, but others were also considered, for example reporting and documentation. RESULTS: Over a 10-month period (September 2018-July 2019), there were three PDSA cycles, which included a total of 195 performed emergency department PoCUS examinations. The implemented quality framework led to 90% of examinations stored to PACS, with a mean of 63%. No negative impacts were reported, and feedback was positive. CONCLUSION: Implementing a quality framework for storing emergency department PoCUS examinations on PACS is feasible and significantly improves practice. Further work is required to sustain and improve the process.

The utility of lung ultrasound in COVID-19: A systematic scoping review.

Introduction: Lung ultrasound (LUS) has an established evidence base and has proven useful in previous viral epidemics. An understanding of the utility of LUS in COVID-19 is crucial to determine its most suitable role based on local circumstances. Method: Online databases, specialist websites and social media platforms were searched to identify studies that explore the utility of LUS in COVID-19. Case reports and recommendations were excluded. Findings: In total, 33 studies were identified which represent a rapidly expanding evidence base for LUS in COVID-19. The quality of the included studies was relatively low; however, LUS certainly appears to be a highly sensitive and fairly specific test for COVID-19 in all ages and in pregnancy. Discussion: There may be LUS findings and patterns that are relatively specific to COVID-19; however, specificity may also be influenced by factors such as disease severity, pre-existing lung disease, operator experience, disease prevalence and the reference standard. Conclusion: LUS is almost certainly more sensitive than chest radiograph for COVID-19 and has several advantages over computed tomography and real-time polymerase chain reaction. High-quality research is needed into various aspects of LUS including: diagnostic accuracy in undifferentiated patients; triage and prognostication; monitoring progression and guiding interventions; the persistence of residual LUS findings; inter-observer agreement and the role of contrast-enhanced LUS.

Osteocyte physiology and response to fluid shear stress are impaired following exposure to cobalt and chromium: Implications for bone health following joint replacement.

The effects of metal ion exposure on osteocytes, the most abundant cell type in bone and responsible for coordinating bone remodeling, remain unclear. However, several studies have previously shown that exposure to cobalt (Co2+ ) and chromium (Cr3+ ), at concentrations equivalent to those found clinically, affect osteoblast and osteoclast survival and function. In this study, we tested the hypothesis that metal ions would similarly impair the normal physiology of osteocytes. The survival, dendritic morphology, and response to fluid shear stress of the mature osteocyte-like cell-line MLO-Y4 following exposure to clinically relevant concentrations and combinations of Co and Cr ions were measured in 2D-culture. Exposure of MLO-Y4 cells to metal ions reduced cell number, increased dendrites per cell and increased dendrite length. We found that combinations of metal ions had a greater effect than the individual ions alone, and that Co2+ had a predominate effect on changes to cell numbers and dendrites. Combined metal ion exposure blunted the responses of the MLO-Y4 cells to fluid shear stress, including reducing the intracellular calcium responses and modulation of genes for the osteocyte markers Cx43 and Gp38, and the signaling molecules RANKL and Dkk-1. Finally, we demonstrated that in the late osteoblasts/early osteocytes cell line MLO-A5 that Co2+ exposure had no effect on mineralization, but Cr3+ treatment inhibited mineralization in a dose-dependent manner, without affecting cell viability. Taken together, these data indicate that metal exposure can directly affect osteocyte physiology, with potential implications for bone health including osseointegration of cementless components, and periprosthetic bone remodeling. © 2016 The Authors. Journal of Orthopaedic Research Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 35:1716-1723, 2017.